High and low lateral approaches to the popliteal artery

Summary Using a series of 20 dissections and two anatomic transverse sections of a lower limb, the authors investigated the lateral approaches to the popliteal artery. The high lateral approach (above the knee) is not very aggressive and gives access to the retro-genicular part of the popliteal artery. After cutaneous and fascial incision, a simple gap between the vastus lateralis and biceps femoris mm. allows easy exposure of the popliteal vessels after backward retraction of the sciatic nerve. The low lateral approach to the artery (below the knee) is very aggressive for the vessels, nerves, and ligaments of the area. It involves the resection of the upper fourth of the fibula and the isolation and protection of the common peroneal nerve Nevertheless, these lateral approaches must be known and used when classic approaches (medial and posteiror) are impossible.

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Voies d'abord latérales hautes et basses de l'artère poplitée

Résumé A partir d'une série de 20 dissections et de deux coupes horizontales d'un membre inférieur congelé, les auteurs ont réalisé une approache anatomique des voies d'abord latérales de l'artère poplitée. L'abord latéral haut de l'artère poplitée (au-dessus du genou) est peu traumatisant et permet d'atteindre la portion rétro-articulaire de l'artère poplitée. Après incision cutanée et fasciale, une simple discision entre les mm. vaste latéral et biceps fémoral permet une exposition aisée des vaisseaux poplités après écartement du n. sciatique en arrière. L'abord latéral bas de l'artère poplitée est très agressif sur les plans vasculaire, nerveux et ligamentaire. Il nécessite la résection du quart supérieur de la fibula en isolant et protégeant le n. fibulaire commun. Néanmoins, ces voies d'abord doivent être connues et utilisées en cas de contre-indication aux voies d'abord classiques (médiales et postérieures).

     

High and low lateral approaches to the popliteal artery

Using a series of 20 dissections and two anatomic transverse sections of a lower limb, the authors investigated the lateral approaches to the popliteal artery. The high lateral approach (above the knee) is not very aggressive and gives access to the retro-genicular part of the popliteal artery. After cutaneous and fascial incision, a simple gap between the vastus lateralis and biceps femoris mm. allows easy exposure of the popliteal vessels after backward retraction of the sciatic nerve. The low lateral approach to the artery (below the knee) is very aggressive for the vessels, nerves, and ligaments of the area. It involves the resection of the upper fourth of the fibula and the isolation and protection of the common peroneal nerve Nevertheless, these lateral approaches must be known and used when classic approaches (medial and posterior) are impossible.     

The morphology and the surgical importance of the gonadal arteries originating from the renal artery

Using dissection and plastic injection followed by corrosion as study methods, we describe 16 cases of gonadal arteries originating from the renal artery. Among them, in 12 cases (75%), we assessed this variation on a single gonadal artery while two gonadal arteries appeared in four cases (25%). In 13 cases (81.25%) the gonadal arteries were located on the left side and in only three cases (18.75%) they were on the right. In seven cases (43.75%), an unique gonadal artery that originated from a single renal artery, in three cases (18.75%) the gonadal artery started from the artery of the inferior segment that started from the anterior branch of the renal artery, in other three cases (18.75%), from the trunk of the renal artery, prior to its terminal ramification and in one case (6.25%), from the artery of the superior segment that started from the anterior branch of the renal artery. In five cases (31.25%), a single gonadal artery started from a supplementary renal artery, in four cases (25%), from double renal arteries (three from the inferior and one from the superior one) and in a single case, from triple renal arteries (from the inferior one). All the four cases (25%) of double gonadal arteries were located on the left. Within them, in two cases, the two gonadal arteries started from the renal artery (unique or supplementary) and in the other two cases, the lateral gonadal artery originated from the renal artery (unique or supplementary) and the medial one from the aorta. This vascular variation shows a significant importance for renal surgery, in partial or total nephrectomy or in the renal transplant as long as it may lead to the compromise of the gonadal blood supply, mostly when the gonadal artery with renal origin is unique, without a second one with aortic or other arterial origin. A gonadal artery with origin from an inferior polar renal artery may be injured during the percutaneous treatment of the syndrome of pielo-ureteral junction, so it becomes a major contraindication. Also, this anatomical variation enhances the importance of the arteriography or Doppler ultrasound examination of the renal hylum. Sometimes, the gonadal artery may pass posterior to the proximal ureter that can be disturbed in traject, leading to hydronephrosis.     

The popliteal region an anatomical study and a new approach to the tibial attachment of the posterior cruciate ligament

Surgical treatment of posterior cruciate ligament injuries is gaining more and more importance. The central posterior approach according to Abbott (1945) has been considered a standard, with various complications involved owing to the local anatomic conditions. This study is intended to present a modified dorsomedial approach to the posterior capsule of the knee joint that is better adapted to the anatomic conditions. As a basis, the popliteal region was dissected in 150 knee joints, and the course of the popliteal artery with its branches as well as the bifurcation of the sciatic nerve were identified. The medial joint line served as a reference point. It has been shown that the knee joint arteries and the two sural arteries arose at relatively constant levels. At least one of the meniscofemoral ligaments was found in all of the knee joints examined the anterior ligament was present in a slightly higher percentage than the posterior ligament. The modified dorsomedial approach to the posterior joint capsule was evaluated in 50 knee joints. Dissection was achieved by blunt division of the medial head of the gastrocnemius muscle, with careful preservation of the proximal vascular supply of that muscle. It was necessary to expose neither the popliteal artery and vein nor the tibial nerve. The tibial attachment of the posterior cruciate ligament could be exposed in every knee. The advantage of the new approach to the posterior cruciate ligament described in this study consists in the preservation of the central neurovascular bundle and the excellent exposure of the tibial attachment.     

The transverse genicular ligament: anatomical study and review of the literature

There is scant information in the literature regarding the transverse genicular ligament. In order to elucidate further the anatomy and controversial function of this structure, we dissected 28 cadavers. This ligament was identified in 55% of knee joints. Morphometrically, we found a mean length and width of this ligament of 35.4 and 2.5 mm, respectively. Two (3.7%) specimens were found to have a duplicated ligament. The mean distance between the anterior attachment site of the anterior cruciate ligament onto the tibia to the transverse genicular ligament was 2.5 mm and the mean distance to this ligament to a midpoint of the tibial tuberosity was 40.5 mm The transverse genicular ligament was found to be slightly taut in extension and lax in flexion of the knee joint. Lateral and medial forces applied manually to the knee had no effect on this ligament. No tension was noted of the transverse genicular ligament with rotation of the knee. With transection of the ligament, no discernable difference in the integrity of the knee joint was observed. The mean tensile strength of this ligament was 67 N. Based on our study, the transverse genicular ligament plays a minimal part in the proper function of the knee joint. Moreover, with only approximately one-half of the knees in our study harboring this structure, one would expect a significant portion of the population to exhibit signs of biomechanical dysfunction of the knee joint which is not the case. This structure may represent a vestigal/insular part of the mesenchyme forming the menisci.     

The anterior intermeniscal ligament of the knee: an anatomic and MR study

Background  The purposes of this study were to identify the presence of the anterior intermeniscal ligament of the knee (AIL), to study its attachment patterns and relationships to other anatomic structures within the knee and to evaluate the potential association of its rupture with other pathology of the knee. Methods  Ten human cadaver knees were dissected excluding knees with surgical scars. Fifty-one MR examinations were performed in symptomatic patients. Arthroscopic observations were carried out on ten patients. Results  AIL was found in nine dissected knees with type I insertion in six cases, type II insertion in three cases. The average length was 31.2 mm (25–45 mm). The average distance between AIL and insertion of the anterior cruciate ligament was 12 mm (11–15 mm). Concerning MR study, AIL was found in 34 cases (82.9%). Four (9.75%) ruptures of the AIL were encountered. Where AIL was intact, 14 patients presented meniscal lesions (46.6%). Where AIL was ruptured, three patients presented meniscal lesions (75%). Conclusion  The present study demonstrates through anatomical and MR studies that AIL is present in more than 80% of the cases with predominant type I insertion. The association of meniscal and AIL lesions was highlighted demonstrating that AIL is not only an anatomical point of interest but also a clinical and surgical reality.     

The transmediastinal arteries of the human testis: an anatomical study

Although the arterial supply of the human testis via the testicular artery is a well-studied subject, the pattern of approach that this vessel takes when reaching the gland is, on the other hand, not as well described. Based on the observation of angiological preparations of 196 adult human testes, the authors describe the presence of transmediastinal testicular vessels in one fourth of the cases. These were of two varieties, as regards the testicular mediastinum: centrifugal and centripetal. The centrifugal vessels were briefly mentioned in the nineteenth century scientific literature, undescribed in twentieth century anatomical studies and only recently referred to in color Doppler ultrasonographic studies; the centripetal vessels are previously undescribed. The authors propose the terms transmediastinal centrifugal and centripetal arteries to designate them.     

Deep flexion helps to avoid popliteal artery injury during all-inside lateral meniscal repair: A cadaveric study

BackgroundArthroscopic meniscus repair rarely leads to major complications such as popliteal artery injury. The distance between the suturing device and the popliteal artery, and the risk of popliteal artery injury at different knee flexion angles during all-inside lateral meniscal repair remain unclear.MethodsAll-inside devices were inserted into 10 human cadaveric knees at the posterior horn of the lateral meniscus through the anterolateral portal at 60°, 90°, and 120° knee flexion; posterior segment of the lateral meniscus through the anterolateral portal at 60°, 90°, and 120°; and anteromedial portal at 90°. Distance and positional relationship between the device and popliteal artery were measured radiographically.ResultsIn posterior horn repair through the anterolateral portal, the median distance increased from 5.7 mm at 60° to 9.1 mm at 90° (P = 0.63) and 18.0 mm at 120° (P = 0.02). The device pushed the wire at 60° in three cases, 90° in one case, and 120° in 0 cases. In posterior segment repair through the anterolateral portal, the median distance was 12.6 mm at 60°, 10.4 mm at 90°, and 18.3 mm at 120° (P = 0.08). The median distance at 90° was 18.1 mm through the anteromedial portal, the same as that at 120° through the anterolateral portal (P = 0.43), but greater than that at 90° through the anterolateral portal (P = 0.04). The wire was not pushed in any case.ConclusionAlthough all-inside repair of the posterior part of the lateral meniscus through the anterolateral portal is risky, deeper knee flexion reduces the risk of popliteal artery injury.     

Clinical importance of the supra-isthmic anastomosis between the superior thyroid arteries in six cases of occlusion of the common carotid artery

Summary In six cases of occlusion of a single common carotid artery, antegrade blood flow was demonstrable in the ipsilateral internal carotid artery by doppler ultrasonography. Antegrade blood flow was also observed in the intracranial portion of the internal carotid artery, comparatively reduced and irregular with respect to that of the corresponding contralateral artery. Studies by color doppler ultrasound and digital subtraction angiography revealed the presence of a collateral arch that passed through the supra-isthmic anastomosis between the superior thyroid arteries. All six subjects examined had presented with neurological deficits that subsequently almost completely regressed. The regression of symptomatology indicates the clinical importance of the collateral circle.

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Importance clinique de l'anastomose supra-isthmique entre les artères thyroïdiennes supérieures dans 6 cas d'occlusion de l'artère carotide commune

Résumé Dans 6 cas d'occlusion d'une seule a. carotide commune, un flux sanguin antérograde dans l'a. carotide interne ipsilatérale a été prouvé par ultrasonographie doppler. Un flux sanguin antérograde était également observé dans la partie intra-crânienne de l'a. carotide interne, mais il était irrégulier et réduit en comparaison avec celui de l'a. homonyme controlatérale. Le doppler couleur et l'angiographie digitalisée avec soustraction ont révélé la présense d'une circulation collatérale qui empruntait l'anastomose supra-isthmique unissant les deux aa. thyroïdiennes supérieures. Ces six patients examinés avaient présenté des déficits neurologiques qui ont ensuite presque complètement régressés. La régression de la symptomatologie indique l'importance clinique de la circulation collatérale.

     

第3腓骨肌应用于韧带重建术的解剖学研究

目的　观察第3腓骨肌（the peroneus tertius,PT）的止点形态并测量相关数据,为PT用于韧带重建术提供解剖学基础。 方法　对34例离体踝关节标本进行测量,记录PT止点至肌腱交界处长度（D1）、止点至伸肌下支持带远端长度（D2）、止点附着处肌肉和肌腱宽度、厚度,并根据止点形态进行分类。 结果　PT止点形态分为4种类型,出现率分别为17.65%、35.29%、41.18%和5.88%。测得D2为（58.12±6.82）mm;D1为（68.22±6.76）mm;PT止点宽度为（32.59±10.61）mm;PT肌腱联合处宽度为（3.91±0.73）mm;PT厚度为（1.12±0.18）mm。PT各形态D2不完全相同,差异具有统计学意义（H＝15.645,P<0.05）。PT各形态D1不完全相同,差异具有统计学意义（H＝15.027,P<0.05）。PT各形态止点宽度不完全相同,差异具有统计学意义（H＝28.098,P<0.05）。PT各形态肌腱交界处宽度不完全相同,差异具有统计学意义（H＝7.919,P<0.05）。PT各形态厚度俱无统计学差异（H＝1.638,P>0.05）。 结论　Ⅲ型止点出现率最高,IV型出现率最低。长度、宽度与体侧、性别无明显差异,但与止点类型存在显著差异。本研究可为临床韧带重建术等手术提供解剖学基础。     

An in vitro biomechanical comparison of anterior cruciate ligament reconstruction: single bundle versus anatomical double bundle techniques

INTRODUCTION: Anterior cruciate ligament ruptures are frequent, especially in sports. Surgical reconstruction with autologous grafts is widely employed in the international literature. Controversies remain with respect to technique variations as continuous research for improvement takes place. One of these variations is the anatomical double bundle technique, which is performed instead of the conventional single bundle technique. More recently, there has been a tendency towards positioning the two bundles through double bone tunnels in the femur and tibia (anatomical reconstruction). OBJECTIVES: To compare, through biomechanical tests, the practice of anatomical double bundle anterior cruciate ligament reconstruction with a patellar graft to conventional single bundle reconstruction with the same amount of patellar graft in a paired experimental cadaver study. METHODS: Nine pairs of male cadaver knees ranging in age from 44 to 63 years were randomized into two groups: group A (single bundle) and group B (anatomical reconstruction). Each knee was biomechanically tested under three conditions: intact anterior cruciate ligament, reconstructed anterior cruciate ligament, and injured anterior cruciate ligament. Maximum anterior dislocation, rigidity, and passive internal tibia rotation were recorded with knees submitted to a 100 N horizontal anterior dislocation force applied to the tibia with the knees at 30, 60 and 90 degrees of flexion. RESULTS: There were no differences between the two techniques for any of the measurements by ANOVA tests. CONCLUSION: The technique of anatomical double bundle reconstruction of the anterior cruciate ligament with bone-patellar tendon-bone graft has a similar biomechanical behavior with regard to anterior tibial dislocation, rigidity, and passive internal tibial rotation.     

An anomalous muscle in the superficial region of the popliteal fossa, with special reference to its innervation and derivation

An anomalous muscle was found in the superficial region of the right popliteal fossa in a 90-year-old Japanese female cadaver during dissection practice for medical students. The muscle ran transversely between the medial head of the gastrocnemius muscle and the tendon of the biceps femoris muscle, covering the nerves, vessels and muscle in the popliteal fossa. The muscle received its nerve supply from the common peroneal nerve. Based on the result of nerve fiber analysis, we speculated that the anomalous muscle might be close to the short head of the biceps femoris muscle in its derivation.     

颈部Berry韧带区的外科解剖

目的 通过对甲状腺手术中最常发生喉返神经损伤的Berry韧带区的解剖,为甲状腺手术中避免喉返神经的损伤提供解剖学基础.方法 对25例(男性15例,女性10例)固定尸体标本进行大体解剖,记录Berry韧带的起止点及其与喉返神经的位置关系.将甲状腺分别向外侧、前内侧提拉,从甲状腺的内、外侧测量喉返神经距Berry韧带甲状腺...     

Posterior approach for simultaneous access to the popliteal and anterior tibial arteries applications to distal arterial bypass

Abstract Arterial surgery to salvage the lower limb tends to make use of the great saphenous vein, harvested with the subject in the supine position. If this is not possible the small saphenous vein is used, harvested with the subject in the prone position, however this requires a peroperative modification of the procedure. A bypass between the popliteal and anterior tibial arteries can be performed using either a lateral or a medial and lateral approach with the patient supine. In the event of trophic disorders of the lateral compartment of the leg, these approaches are not applicable. In such cases we propose a single posterior approach. The single posterior approach was used on 10 lower limbs from 5 cadavers in the prone position. Approach to the lower part of the popliteal artery was undertaken posteriorly between the two heads of gastrocnemius. The small saphenous vein was entirely dissected 10cm above the lateral malleolus, the Achilles tendon and short fibular vessels were retracted medially to expose the interosseous fascia, which was divided over 10 cm. Medial rotation of the limb by 30° exposed the anterior tibial artery. For 3 of the lower limbs an 8 cm fibular resection was necessary, whereas on the remaining 7 medial rotation enabled excellent exposure of the anterior tibial artery. The single posterior approach to the anterior tibial artery can be applied in cases requiring distal bypass, using the small saphenous vein, between the inferior part of the popliteal artery and the anterior tibial artery.     

The relationships of the bile duct and the retroduodenal arteries and their importance in the surgical treatment of hemorrhagic duodenal ulcer

Summary The anatomic relationships of the gastroduodenal artery (GDA) and the posterior superior pancreaticoduodenal artery (PSPD) with the bile duct in their retroduodenal courses were studied in 35 bloc specimens from normal cadavers, injected after removal. The distances between the GDA, the pylorus, and the bile duct were measured in the sagittal plane. The origin and course of the PSPD in relation to the bile duct were studied. The relation of the GDA and the bile duct were divisable into four types: in Type 1 (n=22) the two structures separated progressively, the artery being on the left of the bile ducts; in Type 2: (n=7) the structures approached each other without crossing, Type 3: (n=5) the GDA crossed in front of the bile duct at the level of the first part of the duodenum (D1), Type 4: (n=1) the GDA crossed the bile duct below D1 and ran along its right border. The PSPD originated at the posterior face of D1 in 20% of cases (n=7) and crossed the anterior surface of the bile duct at the posterior surface of D1. In four cases there was no pancreatic tissue between the PSPD and the bile ducs. It follows that the risk of injury to the bile duct when securing hemostasis by transfixing a bleeding duodenal ulcer in the D1 segment is great when the arterial structures (GDA and PSPD) cross the bile duct. This risk is increased when there is no pancreatic tissue between them.

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Rapports du conduit cholédoque et des artères rétroduodénales. Incidences sur le traitement chirurgical de l'ulcère duodénal hémorragique

Résumé Les auteurs ont analysé les rapports anatomiques de l'artère gastroduodénale (AGD) et de l'artère pancréatico-duodénale postérieure et supérieure (APDPS) avec le conduit cholédoque dans leur trajet rétroduodénal à partir de 35 blocs duodéno-pancréatiques sains et injectés après prélèvement. Les distances entre l'AGD, le pylore et le conduit cholédoque ont été mesurées dans le plan frontal. Les distances entre l'AGD et le conduit cholédoque ont également été mesurées dans le plan sagittal. L'origine et le trajet de l'APDPS par rapport au conduit cholédoque ont été étudiés. Les rapports de l'AGD et du conduit cholédoque ont été classés en 4 types : Type 1 (n=22) ces deux éléments s'éloignaient progressivement, l'artère se situant à gauche du conduit cholédoque; Type 2: (n=7) ils se rapprochaient sans se croiser; Type 3 : (n=5) l'AGD croisait le conduit cholédoque par en avant à la face dorsale de la partie supérieure du duodénum (D1) ; Type 4 : (n=1) l'AGD croisait le conduit cholédoque au dessus de D1 et cheminait le long de son bord droit. L'APDPS naissait à la face dorsale de D1 dans 20 % des cas (n=7) et croisait la face ventrale du conduit cholédoque à la face dorsale de D1. Dans 4 cas il n'existait pas d'interposition de tissu pancréatique entre l'APDPS et le conduit cholédoque. Il en résulte que le risque de plaie cholédocienne lors de l'hémostase d'un ulcère hémorragique de D1 par des points transfixiants est important lors d'un croisement des éléments artériels (AGD ou APDPS) et du conduit cholédoque. Ce risque est majoré en l'absence d'interposition de tissu pancréatique.

     

An immunohistochemical study of enthesis development in the medial collateral ligament of the rat knee joint

The changing distributions of collagens and glycosaminoglycans have been studied at the attachments of the medial collateral ligament during postnatal development. The ligament is of particular interest because it has a fibrocartilaginous attachment to the femoral epiphysis, but a fibrous one to the tibial metaphysis. Ligaments were examined in rats killed at birth and at 2, 4, 6, 8, 10, 20, 30, 45, 60, 90 and 120 days after birth. Cryosections were immunolabelled with monoclonal and polyclonal antibodies against types I and II collagen, chondroitin 4 and 6 sulfate, dermatan and keratan sulfate. Although the ligament is attached at both ends to bones that develop from cartilage, there was a striking difference in collagen labelling. Type II collagen was only found in spicules of calcified cartilage in bone beneath the tibial enthesis after ossification had commenced, but there was a continuous band of labelling at all stages of development at the femoral enthesis. Initially, the cartilage at the femoral attachment lacked type I collagen, but by 45 days labelling was continuous from ligament to bone. Continuity of labelling was seen much earlier at the tibial enthesis, as soon as bone had formed. There were also marked changes in glycosaminoglycan distribution. Keratan sulfate was present at both entheses up to 45 days, but only at the femoral enthesis thereafter. Both attachments labelled throughout life for dermatan sulfate, but chondroitin 4 and 6 sulfate were only found at the femoral end. The results suggest that enthesial cartilage at the femoral attachment was initially derived from the cartilaginous bone rudiment but was quickly eroded on its deep surface by endochondral ossification as bone formed at the attachment site. It was replaced by fibrocartilage developing in the ligament. This mechanism allows enthesis cartilage/fibrocartilage to contribute to the growth of a bone at a secondary centre of ossification in addition to dissipating stress at the ligament-bone junction.     

An anomalous muscle in the region of the popliteal fossa: case report

Variations in the hamstring muscles are not common. We describe here a rare anomalous muscle in the popliteal fossa and speculate on its functional significance.     

髂嵴上区动脉的应用解剖学

本文观测了34侧成人标本的髂嵴上区的动脉支,共44支,平均每侧为1.3支,其中每侧1支者占52.9%,管径大于1mm 者38.8%.97.7%动脉支的穿出点集中在髂嵴上方8cm 以内.     

Variations in the lumbosacral ligament and associated changes in the lumbosacral region resulting in compression of the fifth dorsal root ganglion and spinal nerve

Sixty-five lumbosacral regions from adult cadavers were dissected and the position and relations of the lumbosacral ligament noted. The lumbosacral ligament was present in all specimens; in 22 (34%) it extended medially across the ventral ramus of the fifth lumbar nerve, and in six (9%) of these the underlying nerve was compressed and visibly flattened. On two of these specimens the nerve, together with its dorsal root ganglion, was removed, processed, and stained with Masson's trichrome. The compressed nerve showed increased thickness of endoneurial and perineurial connective tissue, and the cells of the dorsal root ganglion were smaller and surrounded by increased connective tissue, particularly at the periphery of the ganglion. Observation of the lumbosacral ligament and surrounding anatomical structures suggests that anatomical variation in this region may be attributed to the health of the lumbosacral articular elements. In those specimens showing compression of the fifth lumbar spinal nerve there was also narrowing of the lumbosacral interspace. In these the disc itself was compressed and showed degenerative changes. The articular processes at the lumbosacral joint were irregular, with thinning and fissuring of the articular cartilage. It is suggested that the processes which lead to the further development of the ligament, by the formation of additional fibrous bands, are mechanical in nature and result from instability at the lumbosacral region itself. Instability subsequently leads to the initiation of a chain of degenerative changes, involving pathology at the lumbosacral disc and zygapophyseal joints. Compression of the dorsal root ganglion occurs either within a narrowed inter vertebral foramen, or in the case described here just external to the foramen, while compression of the nerve occurs in the accessory ligamentous bands formed to resist the instability. A mechanism by means of which compression of the ganglion may give rise to pain is suggested. © 1995 WiIey-Liss, Inc.